Provider Demographics
NPI:1528404456
Name:OLD PUEBLO ACUPUNCTURE PLLC
Entity Type:Organization
Organization Name:OLD PUEBLO ACUPUNCTURE PLLC
Other - Org Name:OLD PUEBLO ACUPUNCTURE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:WOOLSEY
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:520-722-9101
Mailing Address - Street 1:2450 N PANTANO RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-3720
Mailing Address - Country:US
Mailing Address - Phone:520-722-9101
Mailing Address - Fax:
Practice Address - Street 1:2450 N PANTANO RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-3720
Practice Address - Country:US
Practice Address - Phone:520-722-9101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-19
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0850171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty